We describe a case of alpha-gal syndrome (AGS) in a resident of Washington, USA, after local Ixodes pacificus tick bites, which were associated with IgE increases after diagnosis. AGS should be considered a potential cause of anaphylactic and allergic reactions in persons with tick exposures, regardless of geographic residence.

In the United States, alpha-gal syndrome (AGS) is primarily associated with lone star tick (Amblyomma americanum) bites. We describe AGS onset after an Ixodes scapularis tick bite and present AGS surveillance in Maine, 2014-2023. US health and public health professionals should be aware of AGS outside the established lone star tick range.

This case series investigates trends in time from onset of alpha-gal syndrome to diagnosis among patients with disease onset from 1977 to 2019. | eng

Pacific Coast tick fever is a recently described zoonotic disease in California caused by a spotted fever group rickettsia, Rickettsia rickettsii subsp. californica (formerly Rickettsia 364D) and transmitted by the Pacific Coast tick, Dermacentor occidentalis. Like many emerging vector-borne diseases, knowledge regarding the transmission cycle, contribution from potential amplifying hosts, and geographic distribution of R. rickettsii californica is limited. We paired molecular analysis with comparative spatial niche modeling to identify vertebrate hosts potentially involved in the transmission cycle of this pathogen. We identified R. rickettsii californica DNA in three mammal species (Otospermophilus beecheyi, Lepus californicus, and Sylvilagus audubonii). This is the first record of R. rickettsii californica detected in mammals and may indicate potential amplifying hosts for this human pathogen. Species niche modeling of uninfected and infected D. occidentalis identified areas of high suitability along the coast and Sierra Nevada foothills of California. These findings support the hypothesis that amplifying host(s) may support higher infection prevalence in the infected tick regions compared to other parts of the tick's range. Potential host species distribution models (SDMs) were constructed from museum records and niche overlap statistics were used to compare habitat suitability with R. rickettsii californica-infected tick SDMs. We found higher than null overlap of infected ticks with California ground squirrels (O. beecheyii) and trending, but nonsignificant, overlap with two lagomorph species. Pairing molecular and niche modeling may be a useful approach to identify species that are involved in the maintenance of emerging tick-borne zoonoses.

In response to notable increases in tick-associated illnesses in the United States, recent public health policies encouraged multi-sector collaborative approaches to preventing vector-borne diseases. Primary prevention strategies focus on educating the public about risks for tick-borne diseases and encouraging adoption of personal protection strategies. Accurate descriptions of when and where people are at risk for tick-borne diseases aid in the optimization of prevention messaging. Tick and tick-borne pathogen data can be used to fill gaps in epidemiological surveillance. However, the utility of acarological data is limited by their completeness. National maps showing the distribution of medically important tick species and the pathogens they carry are often incomplete or non-existent. Recent policies encourage accelerated efforts to monitor changes in the distribution and abundance of medically important ticks and the presence and prevalence of human pathogens that they carry, and to provide actionable, evidence-based information to the public, health care providers and public health policy makers. In 2018, the Centers for Disease Control and Prevention initiated a national tick surveillance program focused on Ixodes ticks. The national program coordinated and expanded upon existing efforts led by public health departments and academic institutions. Here, we describe experiences of state public health departments engaged in Ixodes tick surveillance, including information on why they initiated Ixodes surveillance programs, programmatic objectives, and strategies for maintaining tick surveillance programs. We share experiences and challenges in interpreting or communicating tick surveillance data to stakeholders and explore how the acarological data are used to complement epidemiological data.

BACKGROUND: Carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPA) are extensively drug resistant bacteria. We investigated the source of a multistate CP-CRPA outbreak. METHODS: Cases were defined as a U.S. patient's first isolation of P. aeruginosa sequence type 1203 with the carbapenemase gene blaVIM-80 and cephalosporinase gene blaGES-9 from any specimen source collected and reported to CDC between January 1, 2022-May 15, 2023. We conducted a 1:1 matched case-control study at the post-acute care facility with the most cases, assessed exposures associated with case status for all case-patients, and tested products for bacterial contamination. RESULTS: We identified 81 case-patients from 18 states, 27 of whom were identified through surveillance cultures. Four (7%) of 54 case-patients with clinical cultures died within 30 days of culture collection, and four (22%) of 18 with eye infections underwent enucleation. In the case-control study, case-patients had increased odds of receiving artificial tears compared to controls (crude matched OR: 5.0, 95% CI: 1.1, 22.8). Overall, artificial tears use was reported by 61 (87%) of 70 case-patients with information; 43 (77%) of 56 case-patients with brand information reported use of Brand A, an imported, preservative-free, over-the-counter (OTC) product. Bacteria isolated from opened and unopened bottles of Brand A were genetically related to patient isolates. FDA inspection of the manufacturing plant identified likely sources of contamination. CONCLUSIONS: A manufactured medical product serving as the vehicle for carbapenemase-producing organisms is unprecedented in the U.S. The clinical impacts from this outbreak underscore the need for improved requirements for U.S. OTC product importers.

During May 2022-April 2023, dengue virus serotype 3 was identified among 601 travel-associated and 61 locally acquired dengue cases in Florida, USA. All 203 sequenced genomes belonged to the same genotype III lineage and revealed potential transmission chains in which most locally acquired cases occurred shortly after introduction, with little sustained transmission.

The flavivirus envelope protein is a class II fusion protein that drives flavivirus-cell membrane fusion. The membrane fusion process is triggered by the conformational change of the E protein from dimer in the virion to trimer, which involves the rearrangement of three domains, EDI, EDII, and EDIII. The movement between EDI and EDII initiates the formation of the E protein trimer. The EDI-EDII hinge region utilizes four motifs to exert the hinge effect at the interdomain region and is crucial for the membrane fusion activity of the E protein. Using West Nile virus (WNV) NY99 strain derived from an infectious clone, we investigated the role of eight flavivirus-conserved hydrophobic residues in the EDI-EDII hinge region in the conformational change of E protein from dimer to trimer and viral entry. Single mutations of the E-A54, E-I130, E-I135, E-I196, and E-Y201 residues affected infectivity. Importantly, the E-A54I and E-Y201P mutations fully attenuated the mouse neuroinvasive phenotype of WNV. The results suggest that multiple flavivirus-conserved hydrophobic residues in the EDI-EDII hinge region play a critical role in the structure-function of the E protein and some contribute to the virulence phenotype of flaviviruses as demonstrated by the attenuation of the mouse neuroinvasive phenotype of WNV. Thus, as a proof of concept, residues in the EDI-EDII hinge region are proposed targets to engineer attenuating mutations for inclusion in the rational design of candidate live-attenuated flavivirus vaccines.

The number of children newly infected with HIV dropped by 50%, from 320 000 in 2010 to 160 000 in 2021. Despite progress, ongoing gaps persist in diagnosis, continuity of care, and treatment optimization. In response, the United States President's Emergency Plan for AIDS Relief created the Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response (FASTER). Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response addressed gaps in countries with the highest unmet need by working with government to operationalize innovative interventions and ensure alignment with national priorities and with communities living with HIV to ensure the change was community-led. Between 2019 and 2021, FASTER's interventions were incorporated into national policies, absorbed by Ministries of Health, and taken up in subsequent awards and country operating plans. Continued effort is needed to sustain gains made during the FASTER initiative and to continue scaling evidence-based interventions to ensure that children and adolescents are not left behind in the global HIV response.

Infection with Borrelia miyamotoi in California, USA, has been suggested by serologic studies. We diagnosed B. miyamotoi infection in an immunocompromised man in California. Diagnosis was aided by plasma microbial cell-free DNA sequencing. We conclude that the infection was acquired in California.

Objectives. To examine the potential impact of contact tracing to identify contacts and prevent mpox transmission among gay, bisexual, and other men who have sex with men (MSM) as the outbreak expanded. Methods. We assessed contact tracing outcomes from 10 US jurisdictions before and after access to the mpox vaccine was expanded from postexposure prophylaxis for persons with known exposure to include persons at high risk for acquisition (May 17-June 30, 2022, and July 1-31, 2022, respectively). Results. Overall, 1986 mpox cases were reported in MSM from included jurisdictions (240 before expanded vaccine access; 1746 after expanded vaccine access). Most MSM with mpox were interviewed (95.0% before vaccine expansion and 97.0% after vaccine expansion); the proportion who named at least 1 contact decreased during the 2 time periods (74.6% to 38.9%). Conclusions. During the period when mpox cases among MSM increased and vaccine access expanded, contact tracing became less efficient at identifying exposed contacts. Public Health Implications. Contact tracing was more effective at identifying persons exposed to mpox in MSM sexual and social networks when case numbers were low, and it could be used to facilitate vaccine access. (Am J Public Health. Published online ahead of print May 4, 2023:e1-e4. https://doi.org/10.2105/AJPH.2023.307301).

Using data from 12 US health departments, we estimated mean serial interval for monkeypox virus infection to be 8.5 (95% credible interval 7.3-9.9) days for symptom onset, based on 57 case pairs. Mean estimated incubation period was 5.6 (95% credible interval 4.3-7.8) days for symptom onset, based on 35 case pairs.

Community health workers advance health equity and foster community-clinical linkages. By promoting culturally relevant care, sharing their own stories, and bridging gaps, they can reach populations burdened with higher rates of chronic diseases due to adverse social determinants of health and structural racism. Given the disproportionate impacts of COVID-19, lessons learned from a forum, an expert group, and a survey showed a need by community health workers for (1) training, (2) health and safety practices, (3) workplace guidance, and (4) mental health resources. Community health workers are integral to expanding access to services and require a robust infrastructure for their growth.

Low-cost particulate matter (PM) sensors provide new methods for monitoring occupational exposure to hazardous substances, such as flour dust. These devices have many possible benefits, but much remains unknown about their performance for different exposure monitoring strategies in the workplace. We explored the performance of PM sensors for four different monitoring strategies (time-weighted average and high time resolution, each quantitative and semi-quantitative) for assessing occupational exposure using low-cost PM sensors in a field study in the industrial bakery sector. Measurements were collected using four types of sensor (PATS+, Isensit, Airbeam2, and Munisense) and two reference devices (respirable gravimetric samplers and an established time-resolved device) at two large-scale bakeries, spread over 11 participants and 6 measurement days. Average PM2.5 concentrations of the low-cost sensors were compared with gravimetric respirable concentrations for 8-h shift periods and 1-min PM2.5 concentrations of the low-cost sensors were compared with time-resolved PM2.5 data from the reference device (quantitative monitoring strategy). Low-cost sensors were also ranked in terms of exposure for 8-h shifts and for 15-min periods with a shift (semi-quantitative monitoring strategy). Environmental factors and methodological variables, which can affect sensor performance, were investigated. Semi-quantitative monitoring strategies only showed more accurate results compared with quantitative strategies when these were based on shift-average exposures. The main factors that influenced sensor performance were the type of placement (positioning the devices stationary versus personal) and the company or workstation where measurements were collected. Together, these findings provide an overview of common strengths and drawbacks of low-cost sensors and different ways these can be applied in the workplace. This can be used as a starting point for further investigations and the development of guidance documents and data analysis methods.

As of November 14, 2022, monkeypox (mpox) cases had been reported from more than 110 countries, including 29,133 cases in the United States.* Among U.S. cases to date, 95% have occurred among males (1). After the first confirmed U.S. mpox case on May 17, 2022, limited supplies of JYNNEOS vaccine (Modified Vaccinia Ankara vaccine, Bavarian Nordic) were made available to jurisdictions for persons exposed to mpox. JYNNEOS vaccine was approved by the Food and Drug Administration (FDA) in 2019 as a 2-dose series (0.5 mL per dose, administered subcutaneously) to prevent smallpox and mpox disease.() On August 9, 2022, FDA issued an emergency use authorization to allow administration of JYNNEOS vaccine by intradermal injection (0.1 mL per dose) (2). A previous report on U.S. mpox cases during July 31-September 3, 2022, suggested that 1 dose of vaccine offers some protection against mpox (3). This report describes demographic and clinical characteristics of cases occurring 14 days after receipt of 1 dose of JYNNEOS vaccine and compares them with characteristics of cases among unvaccinated persons with mpox and with the vaccine-eligible vaccinated population in participating jurisdictions. During May 22-September 3, 2022, among 14,504 mpox cases reported from 29 participating U.S. jurisdictions,() 6,605 (45.5%) had available vaccination information and were included in the analysis. Among included cases, 276 (4.2%) were among persons who had received 1 dose of vaccine 14 days before illness onset. Mpox cases that occurred in these vaccinated persons were associated with lower percentage of hospitalization (2.1% versus 7.5%), fever, headache, malaise, myalgia, and chills, compared with cases in unvaccinated persons. Although 1 dose of JYNNEOS vaccine offers some protection from disease, mpox infection can occur after receipt of 1 dose, and the duration of protection conferred by 1 dose is unknown. Providers and public health officials should therefore encourage persons at risk for acquiring mpox to complete the 2-dose vaccination series and provide guidance and education regarding nonvaccine-related prevention strategies (4).

Data on monkeypox in children and adolescents aged <18 years are limited (1,2). During May 17-September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States,(dagger) primarily among adult gay, bisexual, and other men who have sex with men (3). During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0-12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13-17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)-level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

In August 2022, the Florida Department of Health (FDOH) was notified of a suspected case of monkeypox in an infant aged <2 months who was admitted to a Florida hospital with a rash and cellulitis. This case report highlights findings from the related epidemiologic investigation and describes the public health actions taken. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.* This is the youngest patient with confirmed monkeypox infection in Florida to date.

PURPOSE: The purpose of the National Practice Survey is to understand current trends related to the diabetes care and education specialist's integration into the full care team beyond formal diabetes self-management education and support services. METHODS: The 2021 National Practice Survey (NPS2021) contained 61 questions for all respondents with an additional 56 questions pertaining to specific diabetes care and education segments. An anonymous survey was administered online to respondents who are diabetes care and education specialists or a part of the diabetes care team. Email lists were obtained from the Association of Diabetes Care & Education Specialists (ADCES) and the Certification Board for Diabetes Care and Education (CBDCE). Approximately 39,258 emails were sent, and 3357 were undeliverable, with 3797 surveys completed between February 9 to April 6, 2021, resulting in an 11% response rate. The response rate may have been affected by the COVID-19 public health emergency. RESULTS: Diabetes care and education specialists represent an interprofessional specialty of nurses, dietitians, physicians, pharmacists, health educators, and others. Many respondents reported holding either certification as a Certified Diabetes Care and Education Specialist (CDCES) or being Board Certified in Advanced Diabetes Management (BC-ADM). In addition, there appears to be a slight increase in those trained as a Lifestyle Coach to provide the National Diabetes Prevention Program (CDC Recognized National DPP) compared to NPS2017. Most respondents reported being Caucasian/White (84%), followed by Hispanic or Latinx (7%) and African American/Black and Asian/Asian American (at 4% each), like in previous surveys. Respondents reported diverse care delivery models, including traditional and nontraditional services, and expanded models of care such as population health/risk stratification models, the Chronic Care Model, Accountable Care Organizations, managed care, and others. CONCLUSION: The NPS2021 describes DCES workforce opportunities and challenges. Identifying and addressing those that impact the specialty's sustainability, diversity, and growth will guide strategies for the future workforce and their practice settings. Opportunities identified include embracing diabetes community care coordinators for person-centered delivery of care and education services and supporting frontline health care team members to increase competence and expertise in the prevention of type 2 diabetes, diabetes care, and education/support for related chronic diseases. In addition, as health care evolves, it creates opportunities for the DCESs to demonstrate a broader, key role as part of the diabetes care team.

The western black-legged tick (Ixodes pacificus) is the most frequently identified human-biting tick species in the western United States and the principal vector of at least three recognized bacterial pathogens of humans. A potentially pathogenic Rickettsia species, first described in 1978 and recently characterized as a novel transitional group agent designated as Rickettsia tillamookensis, also exists among populations of I. pacificus, although the distribution and frequency of this agent are poorly known. We evaluated DNA extracts from 348 host-seeking I. pacificus nymphs collected from 9 locations in five California counties, and from 916 I. pacificus adults collected from 24 locations in 13 counties, by using a real-time PCR designed specifically to detect DNA of R. tillamookensis. DNA of R. tillamookensis was detected in 10 (2.9%) nymphs (95% CI: 1.6-5.2%) and 17 (1.9%) adults (95% CI: 1.2-3.0%) from 11 counties of northern California. Although site-specific infection rates varied greatly, frequencies of infection remained consistently low when aggregated by stage, sex, habitat type, or geographical region. Four novel isolates of R. tillamookensis were cultivated in Vero E6 cells from individual adult ticks collected from Alameda, Nevada, and Yolo counties. Four historical isolates, serotyped previously as 'Tillamook-like' strains over 40 yr ago, were revived from long-term storage in liquid nitrogen and confirmed subsequently by molecular methods as isolates of R. tillamookensis. The potential public health impact of R. tillamookensis requires further investigation.

PURPOSE: The purpose of the study is to assess self-reported receipt of diabetes education among people with diabetes and its association with following recommended self-care and clinical preventive care practices. METHODS: We analyzed data from the 2017 and 2018 Behavioral Risk Factor Surveillance System for 61 424 adults (18years) with self-reported diabetes in 43 states and Washington, DC. Diabetes education was defined as ever taking a diabetes self-management class. The association of diabetes education with self-care practices (daily glucose testing, daily foot checks, smoking abstention, and engaging in leisure-time physical activity) and clinical practices (pneumococcal vaccination, biannual A1C test, and an annual dilated eye exam, influenza vaccination, health care visit for diabetes, and foot exam by a medical professional) was assessed. Multivariable logistic regression with predicted margins was used to predict the probability of following these practices, by diabetes education, controlling for sociodemographic factors. RESULTS: Of adults with diabetes, only half reported receiving diabetes education. Results indicate that receipt of diabetes education is associated with following self-care and clinical preventive care practices. Those who did receive diabetes education had a higher predicted probability for following all 4 self-care practices (smoking abstention, daily glucose testing, daily foot check, and engaging in leisure-time physical activity) and all 6 clinical practices (pneumonia vaccination, biannual A1C test, and an annual eye exam, flu vaccination, health care visit, and medical foot exam). CONCLUSIONS: The prevalence of adults with diabetes receiving diabetes education remains low. Increasing receipt of diabetes education may improve diabetes-related preventive care.

The unique physicochemical properties of carbon nanomaterials and their ever-growing utilization generate a serious concern for occupational risk. Pulmonary exposure to these nanoparticles induces local and systemic inflammation, cardiovascular dysfunction, and even cognitive deficits. While multiple routes of extrapulmonary toxicity have been proposed, the mechanism for and manner of neurologic effects remain minimally understood. Here, we examine the cerebral spinal fluid (CSF)-derived peptidomic fraction as a reflection of neuropathological alterations induced by pulmonary carbon nanomaterial exposure. Male C57BL/6 mice were exposed to 10 or 40 µg of multi-walled carbon nanotubes (MWCNT) by oropharyngeal aspiration. Serum and cerebrospinal fluids were collected 4 h post-exposure. An enriched peptide fraction of both biofluids was analyzed using ion mobility-enabled data-independent mass spectrometry for label-free quantification. MWCNT exposure induced a prominent peptidomic response in the blood and CSF; however, correlation between fluids was limited. Instead, we determined that a MWCNT-induced peptidomic shift occurred specific to the CSF with 292 significant responses found that were not in serum. Identified MWCNT-responsive peptides depicted a mechanism involving aberrant fibrinolysis (fibrinopeptide A), blood-brain barrier permeation (homeobox protein A4), neuroinflammation (transmembrane protein 131 L) with reactivity by astrocytes and microglia, and a pro-degradative (signal transducing adapter molecule, phosphoglycerate kinase), anti-plastic (AF4/FMR2 family member 1, vacuolar protein sorting-associated protein 18) state with the excitation-inhibition balance shifted to a hyperexcited (microtubule-associated protein 1B) phenotype. Overall, the significant pathologic changes observed were consistent with early neurodegenerative disease and were diagnostically reflected in the CSF peptidome. Impact Statement These studies demonstrate in a model of nanotube pulmonary exposure that there is a distinct CSF peptidomic response diagnostic of a compromised blood-brain barrier, neuroinflammation, and a hyperexcited neuronal state that is consistent with early-pathobiology of neurodegenerative disease.

Background: Small, lightweight, low-cost optical particulate matter (PM) monitors are becoming popular in the field of occupational exposure monitoring, because these devices allow for real-time static measurements to be collected at multiple locations throughout a work site as well as being used as wearables providing personal exposure estimates. Prior to deployment, devices should be evaluated to optimize and quantify measurement accuracy. However, this can turn out to be difficult, as no standardized methods are yet available and different deployments may require different evaluation procedures. To gain insight in the relevance of different variables that may affect the monitor readings, six PM monitors were selected based on current availability and evaluated in the laboratory; (2) Methods: Existing strategies that were judged appropriate for the evaluation of PM monitors were reviewed and seven evaluation variables were selected, namely the type of dust, within- and between-device variations, nature of the power supply, temperature, relative humidity, and exposure pattern (peak and constant). Each variable was tested and analyzed individually and, if found to affect the readings significantly, included in a final correction model specific to each monitor. Finally, the accuracy for each monitor after correction was calculated; (3) Results: The reference materials and exposure patterns were found to be main factors needing correction for most monitors. One PM monitor was found to be sufficiently accurate at concentrations up to 2000 µg/m(3) PM(2.5), with other monitors appropriate at lower concentrations. The average accuracy increased by up to three-fold compared to when the correction model did not include evaluation variables; (4) Conclusions: Laboratory evaluation and readings correction can greatly increase the accuracy of PM monitors and set boundaries for appropriate use. However, this requires identifying the relevant evaluation variables, which are heavily reliant on how the monitors are used in the workplace. This, together with the lack of current consensus on standardized procedures, shows the need for harmonized PM monitor evaluation methods for occupational exposure monitoring.

BACKGROUND: There is a high risk of Plasmodium vivax parasitaemia following treatment of falciparum malaria. Our study aimed to quantify this risk and the associated determinants using an individual patient data meta-analysis in order to identify populations in which a policy of universal radical cure, combining artemisinin-based combination therapy (ACT) with a hypnozoitocidal antimalarial drug, would be beneficial. METHODS AND FINDINGS: A systematic review of Medline, Embase, Web of Science, and the Cochrane Database of Systematic Reviews identified efficacy studies of uncomplicated falciparum malaria treated with ACT that were undertaken in regions coendemic for P. vivax between 1 January 1960 and 5 January 2018. Data from eligible studies were pooled using standardised methodology. The risk of P. vivax parasitaemia at days 42 and 63 and associated risk factors were investigated by multivariable Cox regression analyses. Study quality was assessed using a tool developed by the Joanna Briggs Institute. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018097400). In total, 42 studies enrolling 15,341 patients were included in the analysis, including 30 randomised controlled trials and 12 cohort studies. Overall, 14,146 (92.2%) patients had P. falciparum monoinfection and 1,195 (7.8%) mixed infection with P. falciparum and P. vivax. The median age was 17.0 years (interquartile range [IQR] = 9.0-29.0 years; range = 0-80 years), with 1,584 (10.3%) patients younger than 5 years. 2,711 (17.7%) patients were treated with artemether-lumefantrine (AL, 13 studies), 651 (4.2%) with artesunate-amodiaquine (AA, 6 studies), 7,340 (47.8%) with artesunate-mefloquine (AM, 25 studies), and 4,639 (30.2%) with dihydroartemisinin-piperaquine (DP, 16 studies). 14,537 patients (94.8%) were enrolled from the Asia-Pacific region, 684 (4.5%) from the Americas, and 120 (0.8%) from Africa. At day 42, the cumulative risk of vivax parasitaemia following treatment of P. falciparum was 31.1% (95% CI 28.9-33.4) after AL, 14.1% (95% CI 10.8-18.3) after AA, 7.4% (95% CI 6.7-8.1) after AM, and 4.5% (95% CI 3.9-5.3) after DP. By day 63, the risks had risen to 39.9% (95% CI 36.6-43.3), 42.4% (95% CI 34.7-51.2), 22.8% (95% CI 21.2-24.4), and 12.8% (95% CI 11.4-14.5), respectively. In multivariable analyses, the highest rate of P. vivax parasitaemia over 42 days of follow-up was in patients residing in areas of short relapse periodicity (adjusted hazard ratio [AHR] = 6.2, 95% CI 2.0-19.5; p = 0.002); patients treated with AL (AHR = 6.2, 95% CI 4.6-8.5; p < 0.001), AA (AHR = 2.3, 95% CI 1.4-3.7; p = 0.001), or AM (AHR = 1.4, 95% CI 1.0-1.9; p = 0.028) compared with DP; and patients who did not clear their initial parasitaemia within 2 days (AHR = 1.8, 95% CI 1.4-2.3; p < 0.001). The analysis was limited by heterogeneity between study populations and lack of data from very low transmission settings. Study quality was high. CONCLUSIONS: In this meta-analysis, we found a high risk of P. vivax parasitaemia after treatment of P. falciparum malaria that varied significantly between studies. These P. vivax infections are likely attributable to relapses that could be prevented with radical cure including a hypnozoitocidal agent; however, the benefits of such a novel strategy will vary considerably between geographical areas.

Opioid use disorder and neonatal abstinence syndrome (NAS) increased in Massachusetts from 1999 to 2013 (1,2). In response, in 2016, the state passed a law requiring birth hospitals to report the number of newborns who were exposed to controlled substances to the Massachusetts Department of Public Health (MDPH)* by mandating monthly reporting of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes related to maternal dependence on opioids (F11.20) or benzodiazepines (F13.20) and to newborns affected by maternal use of drugs of addiction (P04.49) or experiencing withdrawal symptoms from maternal drugs of addiction (P96.1) separately.(†) MDPH uses these same codes for monthly, real-time crude estimates of NAS and uses P96.1 alone for official NAS state reporting.(§) MDPH requested CDC's assistance in evaluating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of either maternal or newborn codes to identify substance-exposed newborns, and of newborn exposure codes (both exposure [P04.49] or withdrawal [P96.1]) and the newborn code for withdrawal alone (P96.1) to identify infants with NAS cases related to three exposure scenarios: 1) opioids, 2) opioids or benzodiazepines, and 3) any controlled substance. Confirmed diagnoses of substance exposure and NAS abstracted from linked clinical records for 1,123 infants born in 2017 and their birth mothers were considered the diagnostic standard and were compared against hospital-reported ICD-10-CM codes. For identifying substance-exposed newborns across the three exposure scenarios, the newborn exposure codes had higher sensitivity (range = 31%-61%) than did maternal drug dependence codes (range = 16%-41%), but both sets of codes had high PPV (≥74%). For identifying NAS, for all exposure scenarios, the sensitivity for either newborn code (P04.49 or P96.1) was ≥92% and the PPV was ≥64%; for P96.1 alone the sensitivity was ≥79% and the PPV was ≥92% for all scenarios. Whereas ICD-10-CM codes are effective for NAS surveillance in Massachusetts, they should be applied cautiously for substance-exposed newborn surveillance. Surveillance for substance-exposed newborns using ICD-10-CM codes might be improved by increasing the use of validated substance-use screening tools and standardized facility protocols and improving communication between patients and maternal health and infant health care providers.

Neonatal withdrawal can be difficult to treat in infants with co-exposure to opiates and gabapentin. Because maternal self-report can underestimate exposures, we evaluated the effect of universal toxicology screening for gabapentin. Identification of co-exposure to opiates and gabapentin increased after implementation of toxicology screening, with implications for improved neonatal care.

BACKGROUND: General population surveys are increasingly offering broader response options for questions on sexual orientation-for example, not only gay or lesbian, but also "something else" (SE) and "don't know" (DK). However, these additional response options are potentially confusing for those who may not know what the terms mean. Researchers studying sexual orientation-based disparities face difficult methodological trade-offs regarding how best to classify respondents identifying with the SE and DK categories. OBJECTIVES: Develop respondent-level probabilities of sexual minority orientation without excluding or misclassifying the potentially ambiguous SE and DK responses. Compare 3 increasingly inclusive analytic approaches for estimating health disparities using a single item: (a) omitting SE and DK respondents; (b) classifying SE as sexual minority and omitting DK; and (c) a new approach classifying only SE and DK respondents with >50% predicted probabilities of being sexual minorities as sexual minority. MATERIALS AND METHODS: We used the sociodemographic information and follow-up questions for SE and DK respondents in the 2013-2014 National Health Interview Survey to generate predicted probabilities of identifying as a sexual minority adult. RESULTS: About 94% of the 144 SE respondents and 20% of the 310 DK respondents were predicted to identify as a sexual minority adult, with higher probabilities for younger, wealthier, non-Hispanic white, and urban-dwelling respondents. Using a more specific definition of sexual minority orientation improved the precision of health and health care disparity estimates. CONCLUSIONS: Predicted probabilities of sexual minority orientation may be used in this and other surveys to improve representation and categorization of those who identify as a sexual minority adult.

BACKGROUND: Influenza virus circulation is monitored through the Cambodian influenza-like illness (ILI) sentinel surveillance system and isolates are characterized by the National Influenza Centre (NIC). Seasonal influenza circulation has previously been characterized by year-round activity and a peak during the rainy season (June-November). OBJECTIVES: We documented the circulation of seasonal influenza in Cambodia for 2012-2015 and investigated genetic, antigenic, and antiviral resistance characteristics of influenza isolates. PATIENTS/METHODS: Respiratory samples were collected from patients presenting with influenza-like illness (ILI) at 11 hospitals throughout Cambodia. First-line screening was conducted by the National Institute of Public Health and the Armed Forces Research Institute of Medical Sciences. Confirmation of testing and genetic, antigenic and antiviral resistance characterization was conducted by Institute Pasteur in Cambodia, the NIC. Additional virus characterization was conducted by the WHO Collaborating Centre for Reference and Research on Influenza (Melbourne, Australia). RESULTS: Between 2012 and 2015, 1,238 influenza-positive samples were submitted to the NIC. Influenza A(H3N2) (55.3%) was the dominant subtype, followed by influenza B (30.9%; predominantly B/Yamagata-lineage) and A(H1N1)pdm09 (13.9%). Circulation of influenza viruses began earlier in 2014 and 2015 than previously described, coincident with the emergence of A(H3N2) clades 3C.2a and 3C.3a, respectively. There was high diversity in the antigenicity of A(H3N2) viruses, and to a smaller extent influenza B viruses, during this period, with some mismatches with the northern and southern hemisphere vaccine formulations. All isolates tested were susceptible to the influenza antiviral drugs oseltamivir and zanamivir. CONCLUSIONS: Seasonal and year-round co-circulation of multiple influenza types/subtypes were detected in Cambodia during 2012-2015.

Middle East Respiratory Syndrome coronavirus (MERS-CoV) causes a highly lethal pulmonary infection with approximately 35% mortality. The potential for a future pandemic originating from animal reservoirs or healthcare-associated events is a major public health concern. There are no vaccines or therapeutic agents currently available for MERS-CoV. Using a probe-based single B cell-cloning strategy, we have identified and characterized multiple neutralizing mAbs specifically binding to the receptor binding domain (RBD) or S1 (non-RBD) regions from a convalescent MERS-CoV-infected patient and from immunized rhesus macaques. RBD-specific mAbs tended to have greater neutralizing potency than non-RBD S1-specific mAbs. Six RBD-specific and five S1-specific mAbs could be sorted into four RBD and three non-RBD distinct binding patterns, based on competition assays, mapping neutralization escape variants, and structural analysis. We determined co-crystal structures for two mAbs targeting RBD from different angles and show they can only bind RBD in the "out" position. We then showed that selected RBD-specific, non-RBD S1, and S2-specific mAbs given prophylactically prevented MERS-CoV replication in lungs and protected mice from lethal challenge. Importantly, combining RBD- and non-RBD mAbs delayed the emergence of escape mutations in a cell-based virus-escape assay. These studies identify mAbs targeting different antigenic sites on S that will be useful for defining mechanisms of MERS-CoV neutralization, and for developing more effective interventions to prevent or treat MERS-CoV infections.IMPORTANCE: MERS-CoV causes a highly lethal respiratory infection for which no vaccines or antiviral therapeutic options are currently available. Based on continuing exposure from established reservoirs in dromedary camels and bats, transmission of MERS-CoV into humans and future outbreaks are expected. Using structurally-defined probes for the MERS-CoV Spike (S) glycoprotein, the target for neutralizing antibodies, single B cells were sorted from a convalescent human and immunized non-human primates (NHPs). mAbs produced from paired immunoglobulin gene sequences were mapped to multiple epitopes within and outside the receptor-binding domain (RBD) and protected against lethal MERS infection in a murine model following passive immunization. Importantly, combining mAbs targeting distinct epitopes prevented viral neutralization escape from RBD-directed mAbs. These data suggest that antibody responses to multiple domains on CoV Spike may improve immunity and will guide future vaccine and therapeutic development efforts.

PROBLEM/CONDITION: Diabetes self-management education (DSME) is a clinical practice intended to improve preventive practices and behaviors with a focus on decision-making, problem-solving, and self-care. The distribution and correlates of established DSME programs in nonmetropolitan counties across the United States have not been previously described, nor have the characteristics of the nonmetropolitan counties with DSME programs. REPORTING PERIOD: July 2016. DESCRIPTION OF SYSTEMS: DSME programs recognized by the American Diabetes Association or accredited by the American Association of Diabetes Educators (i.e., active programs) as of July 2016 were shared with CDC by both organizations. The U.S. Census Bureau's census geocoder was used to identify the county of each DSME program site using documented addresses. County characteristic data originated from the U.S. Census Bureau, compiled by the U.S. Department of Agriculture's Economic Research Service into the 2013 Atlas of Rural and Small-Town America data set. County levels of diagnosed diabetes prevalence and incidence, as well as the number of persons with diagnosed diabetes, were previously estimated by CDC. This report defined nonmetropolitan counties using the rural-urban continuum code from the 2013 Atlas of Rural and Small-Town America data set. This code included six nonmetropolitan categories of 1,976 urban and rural counties (62% of counties) adjacent to and nonadjacent to metropolitan counties. RESULTS: In 2016, a total of 1,065 DSME programs were located in 38% of the 1,976 nonmetropolitan counties; 62% of nonmetropolitan counties did not have a DSME program. The total number of DSME programs for nonmetropolitan counties with at least one DSME program ranged from 1 to 8, with an average of 1.4 programs. After adjusting for county-level characteristics, the odds of a nonmetropolitan county having at least one DSME program increased as the percentage insured increased (adjusted odds ratio [AOR] = 1.10, 95% confidence interval [CI] = 1.08-1.13), the percentage with a high school education or less decreased (AOR = 1.06, 95% CI = 1.04-1.07), the unemployment rate decreased (AOR = 1.19, 95% CI = 1.11-1.23), and the natural logarithm of the number of persons with diabetes increased (AOR = 3.63, 95% CI = 3.15-4.19). INTERPRETATION: In 2016, there were few DMSE programs in nonmetropolitan, socially disadvantaged counties in the United States. The number of persons with diabetes, percentage insured, percentage with a high school education or less, and the percentage unemployed were significantly associated with whether a DSME program was located in a nonmetropolitan county. PUBLIC HEALTH ACTION: Monitoring the distribution of DSME programs at the county level provides insight needed to strategically address rural disparities in diabetes care and outcomes. These findings provide information needed to assess lack of availability of DSME programs and to explore evidence-based strategies and innovative technologies to deliver DSME programs in underserved rural communities.